Palliative Care Nursing Theories for End-of-Life Cases

Overview of Nursing Theory Types

A nursing theory helps structure decisions and practice for the nurse professional (Scribd, 2014). The three major types are the grand theory, the middle-range theory, and the nursing practice theory. The use of any of these theories enables nurses to provide more effective patient care more efficiently. Grand theories deal with the overall nature and goals of nursing, as discussed by Marilyn Parker in Nursing Theories and Nursing Practice. Their scope is broad and synthesizes nursing experience, observations, and scholarship. Middle-range theories deal with specific and applicable concepts and research relevant to nursing practice, making available many practical strategies for delivering quality patient care. Nursing practice theories tackle issues and questions relating to specific populations or settings and provide models to help nurses address day-to-day practice experiences (Scribd, 2014).

The Comfort Theory was developed in the 1990s by Katharine Kolcaba, a clinical nursing specialist in gerontology. Kolcaba (2010) perceived comfort as existing in three forms: relief, ease, and transcendence. She understood patient comfort as occurring across four dimensions — physical, psycho-spiritual, environmental, and socio-cultural. Comfort as relief is achieved when a patient experiencing postoperative pain is given prescribed analgesia. Comfort as ease or contentment is achieved when a patient experiences anxiety and its cause is effectively addressed. Comfort as transcendence is achieved when the patient is able to bear or overcome challenges (Kolcaba, 2010). This theoretical structure is well suited to directing the work and thinking of healthcare providers.

The Comfort Theory

The theory holds that when the healthcare needs of a patient are correctly identified and appropriate nursing interventions are used to respond to those needs, the result enhances the patient's comfort (March, 2009). When this occurs, the patient's health-seeking behavior is encouraged and may increase. This behavior may be internal — such as wound healing or improved oxygenation — or external, such as cooperation in rehabilitation or a peaceful death. Achieving health-seeking behaviors also strengthens institutional integrity by producing improved patient outcomes. As a further consequence, increased institutional integrity leads to the development and better implementation of best practices and policies alongside positive patient outcomes (March, 2009).

The concept of comfort is universal and is therefore a universal goal of healthcare (March, 2009). Although Kolcaba originally conceived of her theory within the nursing domain, she also suggests that an institution committed to meeting the healthcare needs of patients can apply this theory as an institution-wide approach. Doing so requires modifying the application of "nursing interventions" to "comfort interventions" in order to include any healthcare practitioner who adopts the theoretical framework (March, 2009). This theory is both applicable and necessary in meeting the comfort needs of patients with life-limiting illnesses.

Afaf I. Meleis created the Middle-Range Theory of Transitions, which provides a framework for guiding anticipated interventions for older adults with dementia and their caregivers (Rose & Lopez, 2012). Meleis defines transition as a movement between two relatively stable periods — such as a particular life phase, situation, or status — to another. Her theory states that such transitions are driven by certain stimuli or events that require new responses. These new responses in a patient consequently call for new coping strategies (Rose & Lopez, 2012). Dementia and Alzheimer's Disease represent one such life-limiting illness to which this theory is particularly relevant.

The Global Deterioration Scale identifies seven global stages in the Dementia Trajectory based on the patient's cognition and function (Rose & Lopez, 2012). These stages cover both memory loss and functional loss. The stages of memory loss descend from no subjective memory deficit, through very mild decline, mild decline, moderate decline, and moderately severe decline, to very severe decline. Functional loss progressively deteriorates from normal function through feelings of memory lapses, trouble remembering or misplacing items, increased functional difficulty, forgetfulness and difficulty choosing clothing while retaining some independence in basic functions, personality changes, and the eventual need for assistance in all aspects of care — including loss of verbal abilities, rigid muscles, and difficulty swallowing. Key care transitions include obtaining the initial dementia diagnosis, advanced planning for costs and healthcare, cessation of driving, managing behavioral symptoms, changes in care setting, and preparation for end-of-life (Rose & Lopez, 2012).

The Middle-Range Theory of Transitions

Implementation ideally involves palliative care rather than aggressive, life-sustaining care for patients with advanced dementia or Alzheimer's Disease (Rose & Lopez, 2012). Few patients, however, receive this type of care, and many die as a result of burdensome interventions such as hospital transfers, emergency room visits, parenteral therapy, or tube feeding — often accompanied by troubling symptoms such as dyspnea, pain, and restlessness. Obstacles to appropriate palliative care include the failure to recognize dementia as a terminal illness and inadequate communication among providers and families. Many nursing homes also enforce standard life-sustaining rather than palliative care, a culture driven in part by staff shortages and lack of education.

The responsibility for palliative care thus falls largely on family caregivers, who serve as primary decision-makers for patients with advanced dementia. Yet these family caregivers are often not prepared to make appropriate choices in transitioning from aggressive or life-sustaining care to comfort measures. They depend on nurses to guide them in making such decisions, and yet nurses are themselves often reluctant to provide this assistance (Rose & Lopez, 2012).

Nonetheless, nurses must fulfill the important role of assisting family caregivers through these transitions (Rose & Lopez, 2012). Family caregivers face an intensely stressful, burdensome, and emotionally taxing situation in managing these transitions from the time of diagnosis through the death of the patient. Nurses must support these caregivers and help them navigate and survive each stage of the process (Rose & Lopez, 2012).

The lack of palliative care services, combined with physicians' failure to inform patients and families about available options, deprives many of the chance to access appropriate care (Lyles et al., 2011). In this context, nurses should fill the gap by helping patients and families understand and obtain palliative services. The typology of illness journeys is a useful tool for determining the characteristics of care that are appropriate for a given patient and family, and for advising them accordingly. Palliative care is provided to relieve pain and suffering and to improve the quality of life of patients with chronic, incurable, terminal, or serious illnesses and their families. It covers both curative and non-curative treatments and includes hospice care services — the last of which is often needed by patients in advanced cancer stages (Lyles et al., 2011).